Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities.

Journal Article (Journal Article)

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

Full Text

Duke Authors

Cited Authors

  • Toles, M; Leeman, J; Colón-Emeric, C; Hanson, LC

Published Date

  • August 2020

Published In

Volume / Issue

  • 39 / 8

Start / End Page

  • 855 - 862

PubMed ID

  • 29944061

Pubmed Central ID

  • PMC6408978

Electronic International Standard Serial Number (EISSN)

  • 1552-4523

Digital Object Identifier (DOI)

  • 10.1177/0733464818783689


  • eng

Conference Location

  • United States